Child Application

All of the information in this document will be treated confidentially by HCCADC staff.

This form is to be used for children who may be eligible for the Early Head Start, Pre-school Head Start or Pennsylvania Pre-K Programs.

This application does not guarantee acceptance into the programs offered by HCCADC. These programs have income eligibility requirements, which must be verified before a child can be accepted. After submitting the application, you will be contacted by an HCCADC staff member who will let you know if your child may qualify, answer any questions that you may have, and discuss the next steps with you.

The form does not allow you to go back and edit it, please proofread it before submitting

Please check the service you are applying for: *

Services for chldren birth through 3 years old

Services for children 3 to 5 years old

Childs First Name *

Childs Middle Name *

Childs Last Name *

Childs Sex *

Male

Female

Does the Child have a disability? *

Yes

Is this child a foster child? *

Yes

Childs Birth Date (mm/dd/yyyy) *

Mailing Address *

City *

State *

Zip Code *

County *

Phone *

Parent/Guardian Information:

First Parent/Guardian First Name *

Last Name *

Relationship to Child *

Second Parent/Guardian Information (If Single leave blank)

First Name

Last Name

Relationship to Child

Child lives with: *

Both Parents/Guardians

Father

Mother

Other

Family Size *

Number of people supported by the above income

Directions

Please provide directions to your home and the physical address if different from the mailing address. If you home sits back off the road, please explain how to get there.

Type Parent or Guardian Name *

By typing my name, I am certifiying that the information have provided is accurate; I understand this information will be used to determine child eligibility in HCCADC programs; I understand that HCCADC has income eligibility requirements and priorities when enrolling children.